560 FW 7
Environmental Compliance Auditing

Supersedes 560 FW 7, 11/02/09

Date:  June 4, 2015

Series: Pollution Control

Part 560: Pollution at FWS Facilities

Originating Office: Division of Engineering

 

 

PDF Version

 


7.1 What is the purpose of this chapter? This chapter provides guidance for conducting environmental compliance audits at U.S. Fish and Wildlife Service (Service) facilities.

 

7.2 What are the objectives of the environmental auditing program? The objectives of our auditing program are to:

 

A. Establish Servicewide standards for audits to ensure compliance with applicable environmental laws and regulations; and

 

B. Assure the Director and program managers that we effectively address environmental problems that could:

 

(1) Impact our mission effectiveness,

 

(2) Jeopardize the health of our personnel or the general public,

 

(3) Significantly degrade the environment,

 

(4) Expose the Service to financial liabilities as a result of noncompliance,

 

(5) Erode public confidence in the Service and the U.S. Department of the Interior (Department), and

 

(6) Expose individuals to civil and criminal liability.

 

7.3 What are the authorities for this chapter?

 

A. 515 DM 2, Environmental Auditing.

 

B. Executive Order 13693, Planning for Federal Sustainability in the Next Decade.

 

7.4 Who is responsible for administering the program? See Table 7-1.

 

Table 7-1: Responsibilities for the Environmental Compliance Audit Program

These Service employees…

Are responsible for…

A. The Director

Approving policy for our environmental compliance auditing program.

B. The Assistant Director – Business Management and Operations

Leading the overall administration of the program.

 

C. Regional Directors

(1) Ensuring that their facilities are in compliance with environmental laws and regulations,

 

(2) Implementing the environmental compliance auditing program in their Regions, and

 

(3) Designating a Regional Environmental Compliance Coordinator (RECC).

D. The Chief, Division of Engineering

Providing guidance, funding, and support for the establishment, management, quality control, and implementation of the program.

 

E. The Chief, Environmental Compliance Branch (ECB)

 

(1) Establishing, managing, and overseeing quality control for the program;

 

(2) Providing audit training for Regional personnel;

 

(3) Managing a national database to track audit findings—the Environmental Facility Compliance Audit Tracking System (EFCATS);

 

(4) Visiting one site in each Region at least every 3 years for a formal audit (see section 7.10A). This ensures the quality of the auditing program and consistency among the Regions; and

 

(5) Recommending funding for audits to the Chief, Division of Engineering.

F. The RECCs

(1) Planning, conducting, and tracking audits and corrective actions in their Regions;

 

(2) Providing technical assistance to field stations on environmental compliance issues and completion of the Locations of Concern (LOC) and the Environmental Compliance Checklist (ECC) questionnaires;

 

(3) Identifying funding needs for environmental compliance issues, and managing and allocating the available funding to the field stations based on the priority of the compliance issue;

 

(4) Ensuring that the LOC and ECC questionnaires are completed by the field station before any environmental compliance audit;

 

(5) Notifying the Chief, ECB of any notices of violation or administrative orders; and

 

(6) Obtaining copies of asbestos surveys conducted at locations that are being audited (see 561 FW 8).

 

G. Project Leaders/Facility Managers

(1) Ensuring their facilities are in compliance with environmental regulations and policy;

 

(2) Correcting open audit finding deficiencies through proposed corrective actions and requesting funding to do so;

 

(3) Ensuring that the LOC and ECC questionnaires are complete; and

 

(4) Identifying a Field Station Environmental Contact (FSEC) and ensuring that appropriate staff are available to assist the environmental compliance auditor(s).

H. Field Station Environmental Contact (FSEC)

(1) Attending required environmental compliance training;

 

(2) Assisting with completion of LOC and ECC questionnaires, as needed;

 

(3) Assisting the RECC before, during, and after the informal/formal environmental compliance audit;

 

(4) Updating the RECC about the status of any unresolved corrective actions;

 

(5) Providing environmental records for review, including all asbestos surveys conducted at the field station; and

 

(6) Notifying the Project Leader/Facility Manager and RECC of any environmental compliance concerns at the field station.

 

7.5 How does the Service implement the program?

 

A. Environmental Compliance Audit Process. We conduct two types of environmental compliance audits at Service facilities—informal and formal. Table 7-2 identifies the audit process and documentation requirements.

 

Table 7-2: Environmental Compliance Audit Process

Type of Audit

 Audit Process

Documenting and Tracking Results

Informal Environmental Compliance Audit

(1) The RECC notifies the Project Leader/Facility Manager at least 60 days in advance that they will be receiving an environmental compliance audit. The RECC requests that the LOC and ECC questionnaires be completed.

 

(2) The RECC contacts the field station to review the LOC and ECC questionnaires and determine, based on professional judgment of the severity and complexity of environmental issues at the station, whether an informal audit is warranted.

 

(3) The RECC generally conducts the informal audit from the Regional office, based on his/her audit plan. The RECC completes the audit using the The Environmental Assessment and Management (TEAM) Guide (Federal), State TEAM Guide Supplements, and the Service TEAM Guide Supplement (see section 7.8).

 

(1) The Project Leader/Facility Manager certifies the LOC and ECC questionnaires.

 

(2) The RECC documents the informal audit in EFCATS.

Formal Environmental Compliance Audit

 

(1) The RECC notifies the Project Leader/Facility Manager at least 60 days in advance that they will be receiving an environmental compliance audit. The RECC requests that the LOC and ECC questionnaires be completed.

(2) The Project Leader/Facility Manager ensures that the LOC and ECC questionnaires have been reviewed and updated at least 30 days before the audit date.

(3) The RECC conducts the formal audit according to his/her audit plan. The RECC visits the site and researches records, interviews employees, and surveys the site for compliance. The RECC completes the audit using the The Federal TEAM Guide, State TEAM Guide Supplements, and the Service TEAM Guide Supplement (see section 7.8). 

(4) The RECC obtains a copy of all asbestos surveys conducted at the location.

 

(1) The Project Leader/Facility Manager certifies the LOC and ECC questionnaires.

(2) The RECC documents the formal audit in EFCATS.

 

B. Scheduling and Frequency of Audits.

 

(1) Every year, the RECCs determine the schedule for audits and provide copies of the schedule to the ECB no later than September 1. The ECB uses the schedule to allocate funding to the RECCs for the audits.

 

(2) Audit frequency depends on the size and type of the facility. The Service must audit every facility at least every 5 years.

 

(3) The Service audits fish hatcheries every 3 years due to the complexity of their operations.

 

(4) Some facilities, such as a stand-alone office with only two full-time employees, may not require an audit. The RECC determines this based on professional judgment of the environmental issues present at the station.

 

7.6 What are the types of findings from audits? Table 7-3 shows how we rank and classify audit findings.

 

Table 7-3: Audit Findings

These Findings…

Mean…

A. Negative Regulatory Findings:

(1) Significant Regulatory

 

·        Poses, or has a high likelihood to pose, a direct and immediate threat to human health, safety, the environment, or the facility's mission.

·        Requires immediate attention. RECCs must immediately report significant findings to their Regional Director and the Chief, ECB.

(2) Major Regulatory

·        May pose a threat to human health, safety, or the environment.

·        Requires action, but not necessarily immediate action.

(3) Minor Regulatory

·        Usually administrative in nature, even though it might result in a notice of violation from a regulatory agency.

·        May also include temporary or occasional instances of noncompliance.

B. Positive Regulatory Findings: A “positive” regulatory finding means we are performing the regulated activity in a way that is an exemplary standard of good environmental management, or the facility is demonstrating an effort to exceed requirements.

C. Required Practices: A required practice is an activity governed by Executive Orders or Departmental or Service policy.

(1) Negative Finding

·        A “negative” finding means the facility is not performing the required activity, or is not performing it in compliance with Executive Orders or Departmental or Service policy. 

(2) Positive Finding

·        A “positive” finding means the Service is performing the activity in a way that is an exemplary standard of good environmental management, or the facility is demonstrating an effort to exceed requirements. 

D. Management Practices: A management practice is an activity that is not required by Executive Order or policy.

(1) Negative Finding

·        A “negative” finding means a poor management practice.

(2) Positive Finding

·        A “positive” finding means going above and beyond a recommended practice.

 

7.7 How does the Service document compliance findings after informal and formal audits?

 

A. The RECC must write a Draft Findings Report within 30 days after completing the audit. RECCs use the following sections in their reports:

 

(1) Section One is an executive summary that describes:

 

(a) The facility/site audited,

 

(b) The audit date,

 

(c) What the auditor/team audited,

 

(d) A list of the members of the audit team, and

 

(e) A summary of findings.

 

(2) Section Two contains background information on the site.

 

(3) Section Three reports environmental compliance findings. This section explains the ratings and gives recommendations for corrections.

 

B. The RECC sends a copy of the Draft Findings Report to the Project Leader/Facility Manager.

 

(1) The Project Leader/Facility Manager has 60 days after receiving the report to develop corrective actions for each of the regulatory, required practice, and management practice findings and send them to the RECC.

 

(2) A reply can be as simple as "situation corrected on June 30" or "work order request submitted on May 30, for construction of cement pad." It can also be a detailed corrective action plan.

 

C. If the facility has received a significant regulatory finding, the RECC also must send a copy of the report to the Regional Director.

 

D. The RECC issues a final report within 30 days of receiving the reply on the draft report. If a reply/corrective action is not appropriate to the finding, the RECC contacts the facility to resolve the issue. The RECC sends final copies of the report to the Project Leader/Facility Manager.

 

E. The RECC must monitor the progress of corrective actions.

 

(1) The RECC periodically requests that the Project Leader/Facility Manager report the status of corrective actions.

 

(2) The Project Leader/Facility Manager reports to the RECC 12 months after the Final Findings Report on the status of corrective actions. He/she must report to the RECC every 12 months until all corrective actions are complete.

 

(3) The RECC updates the status of corrective actions in EFCATS. We use this data to track the status of open deficient findings, to manage the auditing program, and to assist in developing budget requests for corrective actions.

 

7.8 What is the TEAM Guide?

 

A. The Chief, ECB is responsible for ensuring the most current versions of the Federal TEAM Guide and State and Service TEAM Guide Supplements are available for Service use. To establish consistency, all of the RECCs use the TEAM Guide and its established standards when they write compliance reports.

 

B. The U.S. Army Corps of Engineers (USACE) prepares and maintains the TEAM Guide. The guide includes protocols for compliance with applicable environmental standards that RECCs, Project Leaders/Facility Managers, and FSECs use as a reference. The categories of protocols are:

 

(1) Air Emissions Management: air pollution from vehicles and equipment operated on the facility;

 

(2) Hazardous Materials Management: storage and handling of chemicals used at the facility;

 

(3) Hazardous Waste Management: generation, storage, transportation, treatment, and disposal of any type of hazardous waste on the facility;

 

(4) Other Environmental Issues: implementation of greening practices at the facility;

 

(5) Pesticide Management: use, storage, and handling of pesticides at the facility;

 

(6) Petroleum Oils and Lubricants (POL) Management: use, storage, and handling of fuels and lubricating oils used at the facility;

 

(7) Solid Waste Management: collection, storage, and disposal of nonhazardous trash, rubbish, and garbage generated on the facility;

 

(8) Storage Tank Management: operation and maintenance of tanks (both aboveground and underground) that store hazardous materials, petroleum products, or hazardous waste;

 

(9) Toxic Substance Management: management of any asbestos, lead-based paint, radon, or polychlorinated biphenyls (PCBs) located at the facility;

 

(10) Wastewater Management: management of any wastewater that is discharged from the facility; and

 

(11) Water Quality Management: management of drinking water systems on the facility.

 

7.9 What training opportunities are available for employees involved in the environmental compliance audit program?

 

A. The Chief, ECB:

 

(1) Is responsible for ensuring audit training is available for RECCs; and

 

(2) Holds bi-monthly conference calls with the RECCs to evaluate program objectives, discuss any ongoing concerns, and address questions.

 

B. Training:

 

(1) The ECB conducts environmental compliance audit training for RECCs every 2 years, or more often if necessary. This training is held at different Service field stations. Part of the class is an actual on-site environmental compliance audit of the host facility.

 

(2) Each trainee receives a certificate documenting their successful completion of the audit training class.

 

7.10 What does the Service do to ensure quality control of the program?

 

A. Once every 3 years, staff in the ECB accompany each RECC on at least one audit to evaluate his/her technical, organizational, and communication skills. ECB staff document these evaluations on FWS Form 3-2136, the Quality Assurance Environmental Team Evaluation Form (or they may use a similar form).

 

B. To ensure auditors/audit teams are performing well, the RECCs must provide an evaluation form (FWS Form 3-2135, Quality Assurance Environmental Team Evaluation Facility Response or a similar form) to each facility being audited so that they can evaluate the auditor(s). These forms are available on EFCATS and on our Forms Web site.

 

C. The ECB schedules an outside evaluator (e.g., USACE) to accompany an audit team to at least one Service facility each year. This evaluator provides a report to the ECB and the RECC containing objective feedback on the Service’s audit process.

 

D. The ECB:

 

(1) Monitors EFCATS to ensure consistency and quality in report writing;

 

(2) Uses quality assurance/quality control (QA/QC) to measure the effectiveness of the program by reviewing replies from the Project Leaders/Facility Managers, self evaluations, and evaluations by people outside the Service; and

 

(3) Maintains a file of the results of the QA/QC program and evaluates it to monitor trends and determine if corrective actions are needed.

 

E. An important part of our QA/QC program is tracking open deficient audit findings and the accomplishment of their corrective actions. Achieving positive results from corrective actions reflects the commitment of managers to the program. Subsequent audits also reveal if repeat open deficient audit findings are occurring. Repeat deficient audit findings may be due to neglect or lack of funding. To ensure this tracking takes place, the ECB provides an open finding status report to the RECCs every other month.

 


For information on the content of this chapter, contact the Division of Engineering. For more information about this Web site, contact Krista Bibb of the Division of Policy, Performance, and Management Programs. 


 

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